Method and pharmaceutical composition for use in the treatment of diabetes

ABSTRACT

The present invention relates to an APJ receptor agonist for use in the treatment or the prevention of diabetes.

FIELD OF THE INVENTION

The present invention relates to an APJ receptor agonist for use in thetreatment or the prevention of diabetes.

BACKGROUND OF THE INVENTION

Diabetes is a disease characterized by failure of insulin feedback andsecretion in the beta cells of the pancreatic islets of Langerhans andis one of the most common endocrine diseases across all age groups andpopulations. The most obvious metabolic effect in diabetes is chronic,erratic elevation of the blood glucose level which is associated withprogressive damage to blood vessels. This may lead to heart attack,stroke, blindness, peripheral nerve dysfunction, and kidney failure.Presently there are 18.2 million people in the United States alone whohave diabetes. In addition to the clinical morbidity and mortality, theeconomic cost of diabetes is huge, exceeding $90 billion per year in theUnited States alone, and the prevalence of diabetes is expected toincrease.

There are two major forms of diabetes mellitus: insulin-dependent(Type 1) diabetes mellitus which accounts for 5 to 10% of all cases, andnon-insulin-dependent (Type-II) diabetes mellitus which comprisesroughly 90 to 95% of cases.

Type I diabetes mellitus is an autoimmune disease characterized byprogressive destruction of pancreatic beta-cells and most oftenoccurring in children and young adults. The disease is associated withhigh rate of severe irreversible complications which occur despite theavailability of insulin replacement, usually through injectionsadministered 1-4 times daily.

Most therapeutic strategies for treatment or prevention of type Idiabetes mellitus are directed to suppression of the autoimmune responsein order to prevent beta-cell destruction. Accordingly, variousimmunosuppressive agents have been considered for preventing destructionof pancreatic beta-cells have been attempted, such as glucocorticoids,cyclophosphamide, cyclosporin A, rapamycin, FK506 and prodigiosin.However, the use of such immunosuppressive agents may cause severe sideeffects such as drug-related toxicity to liver or kidney and to increaseincidence of infectious complications, particularly in patients withdiabetes mellitus that are already susceptible to infections as part oftheir disease.

Type-II diabetes results from a loss of insulin production combined withbody's inability to properly use insulin (insulin resistance), and isoftentimes associated with obesity and aging. In Type II diabetes,patients typically begin therapy by following a regimen of an optimaldiet, weight reduction and exercise. Drug therapy is initiated whenthese measures no longer provide adequate metabolic control. Initialdrug therapy includes: sulfonylureas (for example, tolbutamide,chlorpropamide and glibenclamide), biguanides (for example, metforminand buformin) and a-glucosidase inhibitors (for example, acarbose andvoglibose). However, over 50% of all diabetics treated by presentlyavailable drugs demonstrate poor glycemic control within six years, andrequire insulin replacement therapy as the last resort.

Although many of the symptoms of diabetes mellitus may be controlled byinsulin therapy, the long-term complications of both type I and type IIdiabetes mellitus are severe and may reduce life expectancy by as muchas one third. Over time, elevated blood glucose levels damage bloodvessels, the heart, eyes, kidneys, nerves, autonomic nervous system,skin, connective tissue, and white blood cell function.

Moreover, insulin therapy may result in insulin allergy, insulinresistance, atrophy of the subcutaneous fat at the site of insulininjection (i. e., lipoatrophy), enlargement of subcutaneous fat deposit(i. e., lipohypertrophy) due to lipogenic action of high localconcentration of insulin, and insulin edema.

There is thus a widely recognized need for, and it would be highlyadvantageous to have new, safe and effective therapies for diabetesmellitus.

SUMMARY OF THE INVENTION

The inventors show, thanks to a translational clinical research project,that the use of apelin in humans has a positive effect on insulinsensitivity with a good tolerance and a good safety.

Thus, a first object of the invention relates to an APJ receptor agonistfor use in the treatment or the prevention of diabetes.

DETAILED DESCRIPTION OF THE INVENTION APJ Receptor Agonist and UsesThereof

A first object of the invention relates to an APJ receptor agonist foruse in the treatment or the prevention of diabetes.

As used herein, “diabetes” refers to the broad class of metabolicdisorders characterized by impaired insulin production and glucosetolerance. Diabetes includes type 1 and type 2 diabetes, gestationaldiabetes, prediabetes, insulin resistance, metabolic syndrome, impairedfasting glycaemia and impaired glucose tolerance. Type 1 diabetes isalso known as Insulin Dependent Diabetes Mellitus (IDDM). The terms areused interchangeably herein. Type 2 is also known asNon-Insulin-Dependent Diabetes Mellitus (NIDDM).

Thus, in a particular embodiment, the invention relates to an APJreceptor agonist for use in the treatment or the prevention of diabetesmellitus.

In another particular embodiment, the invention relates to an APJreceptor agonist for use in the treatment or the prevention of type 1diabetes.

In another particular embodiment, the invention relates to an APJreceptor agonist for use in the treatment or the prevention of type 2diabetes.

In another particular embodiment, the invention relates to an APJreceptor agonist for use in the treatment or the prevention of insulinresistance.

The term “APJ receptor” intends the receptor for apelin originallyidentified by O'Dowd et al. (O'Dowd et al, 1993, Gene 136: 355360).

As used herein the term “APJ receptor agonist” refers to any compound,natural or not, capable of promoting the APJ receptor function. Examplesof the APJ receptor agonists of the present invention include but arenot limited to polypeptides, apelinomimetics, antibodies, aptamers andsmall organic molecules (Apelin receptors: from signaling toantidiabetic strategy; C. Chaves-Almagro, I. Castan-Laurell, C. Dray, C.Knauf, et al; Eur J Pharmacol 2015 Sep. 22; 763(Pt B): 149-59. Epub 2015May).

Agonistic activities of a test compound toward APJ receptor may bedetermined by any well known method in the art. For example, since theagonist of the present invention can promote the function of the APJreceptor, the agonist can be screened using the natural agonist of APJreceptor (i.e. apelin) and its receptor. Typically, the agonist of thepresent invention can be obtained using the method screening thesubstance promoting the function of the APJ receptor, which comprisescomparing (i) the case where apelin is brought in contact with the APJreceptor and (ii) the case where a test compound is brought in contactwith the APJ receptor. In the screening method of the present invention,for example, (a) the binding amounts of apelin to the APJ receptor aremeasured (i) when apelin is brought in contact with the APJ receptor and(ii) apelin and a test compound are brought in contact with the APJreceptor; and comparing the results; or, (b) cell stimulating activities(e.g., the activities that promote arachidonic acid release,acetylcholine release, intracellular Ca²⁺ release, intracellular cAMPproduction, intracellular cGMP production, inositol phosphateproduction, changes in cell membrane potential, phosphorylation ofintracellular proteins, activation of c-fos, pH changes, etc.) mediatedby the APJ receptor are measured (i) when apelin is brought in contactwith the APJ receptor and (ii) a test compound is brought in contactwith the APJ receptor; and comparing the results. Typically, the testcompounds that provide a higher promotion or at least the same promotionof APJ receptor than apelin are then selected as APJ receptor agonists.Specific examples of the screening method of the present inventioninclude: (1) a method of screening the substance promoting the functionof the APJ receptor, which comprises measuring the binding amounts oflabeled apelin to the APJ receptor when the labeled apelin is brought incontact with the APJ receptor and when the labeled apelin and a testcompound are brought in contact with the APJ receptor; and comparing theamounts; (2) a method of screening the substance promoting the functionof the APJ receptor, which comprises measuring the binding amounts oflabeled apelin to a cell containing the APJ receptor or a membranefraction of the cell, when the labeled apelin is brought in contact withthe cell or membrane fraction and when the labeled apelin and a testcompound are brought in contact with the cell or membrane fraction, andcomparing the binding amounts; and, (3) a method of screening thesubstance promoting the function of the APJ receptor, which comprisesmeasuring the binding amounts of labeled apelin to the APJ receptorexpressed on a cell membrane by culturing a transformant having a DNAencoding the APJ receptor, when the labeled apelin is brought in contactwith the APJ receptor and when the labeled apelin and a test compoundare brought in contact with the APJ receptor, and comparing the bindingamounts. In those examples, the test compounds that provide a higherbinding or at least the same binding as apelin are then selected as APJreceptor agonists. Specifically, a method for determining whether acompound is an APJ receptor agonist is described in Iturrioz X. et al.(Iturrioz X, Alvear-Perez R, De Mota N, Franchet C, Guillier F, LerouxV, Dabire H, Le Jouan M, Chabane H, Gerbier R, Bonnet D, Berdeaux A,Maigret B, Galzi J L, Hibert M, Llorens-Cortes C. Identification andpharmacological properties of E339-3D6, the first nonpeptidic apelinreceptor agonist. FASEB J. 2010 May; 24(5):1506-17. Epub 2009 Dec. 29).The US Patent Application Publication NO. US 2005/0112701 also describeda test system for the identification of a ligand for angiotensionreceptor like-1 (APJ receptor) comprising an APJ receptor. Anothermethod is also described in the US Patent Publication U.S. Pat. No.6,492,324.

In one embodiment, the APJ receptor agonist is a small organic molecule.The term “small organic molecule” refers to a molecule of a sizecomparable to those organic molecules generally used in pharmaceuticals.The term excludes biological macromolecules (e.g., proteins, nucleicacids, etc.). Preferred small organic molecules range in size up toabout 5000 Da, more preferably up to 2000 Da, and most preferably up toabout 1000 Da.

Examples of small organic molecules that are APJ receptor agonistsinclude those described in the European Patent Application PublicationNo. EP19030052 and in Iturrioz X. et al. (Iturrioz X, Alvear-Perez R, DeMota N, Franchet C, Guillier F, Leroux V, Dabire H, Le Jouan M, ChabaneH, Gerbier R, Bonnet D, Berdeaux A, Maigret B, Galzi J L, Hibert M,Llorens-Cortes C. Identification and pharmacological properties ofE339-3D6, the first nonpeptidic apelin receptor agonist. FASEB J. 2010May; 24(5):1506-17. Epub 2009 Dec. 29). Typically, a small organicmolecule that is an APJ receptor agonist has the general formula (I):

wherein:

R1 is an aryl, alkylaryl, heteroaryl or alkylheteroaryl group

R2 is a hydrogen atom or an aryl group

R3 and R4 represent a hydrogen atom or a heterocycloalkyl groupproviding that R3 and R4 cannot represent simultaneously a hydrogen andthat R3 and R4 can both be part of a heterocycloalkyl group

R5 represents a group selected from the group consisting of boc, fmoc,texas red, patent blue V, lissamine, and rhodamine 101

n is an integer from 0 to 1

Y represents —CO—(NH)_(n′)-A-NH— group with:

-   -   n′ is an integer from 0 to 1    -   A is a group selected from the group consisting of:    -   —(CH₂)_(n″)—    -   —[(CH₂)₂—O]_(n″′)—(CH₂)₂—    -   —(CH₂)_(m)—NH—CO—(CH₂)_(m′)—    -   —(CH₂)_(m)—NH—CO—(CH₂)_(m′)—NH—CO—(CH₂)_(m″)—    -   —(CH₂)_(m)—CO—NH—(CH₂)_(m′)—    -   —(CH₂)_(m)—CO—NH—(CH₂)_(m′)—CO—NH—(CH₂)_(m″)—    -   with n″ representing an integer from 1 to 20    -   with n″′ representing an integer from 1 to 10    -   with m, m′ and m″ representing independently from the other an        integer from 1 to 15    -   X represents a group chosen in the following list:

Alternatively, the APJ receptor agonist may consist in an antibody (theterm including “antibody portion”).

In one embodiment of the antibodies or portions thereof describedherein, the antibody is a monoclonal antibody, or a portion thereof thatbinds to the APJ receptor. In one embodiment of the antibodies orportions thereof described herein, the antibody is a polyclonalantibody, or a portion thereof that binds to the APJ receptor. In oneembodiment of the antibodies or portions thereof described herein, theantibody is a humanized antibody, or a portion thereof that binds to theAPJ receptor. In one embodiment of the antibodies or portions thereofdescribed herein, the antibody is a chimeric antibody, or a portionthereof that binds to the APJ receptor. In one embodiment of theantibodies or portions thereof described herein, the portion of theantibody comprises a light chain of the antibody. In one embodiment ofthe antibodies or portions thereof described herein, the portion of theantibody comprises at least a heavy chain of the antibody. In oneembodiment of the antibodies or portions thereof described herein, theportion of the antibody comprises a Fab portion of the antibody. In oneembodiment of the antibodies or portions thereof described herein, theportion of the antibody comprises a F(ab′)₂ portion of the antibody. Inone embodiment of the antibodies or portions thereof described herein,the portion of the antibody comprises at least a Fc portion of theantibody. In one embodiment of the antibodies or portions thereofdescribed herein, the portion of the antibody comprises a Fv portion ofthe antibody. In one embodiment of the antibodies or portions thereofdescribed herein, the portion of the antibody comprises a variabledomain of the antibody. In one embodiment of the antibodies or portionsthereof described herein, the portion of the antibody comprises one ormore CDR domains of the antibody.

As used herein, “antibody” includes both naturally occurring andnon-naturally occurring antibodies. Specifically, “antibody” includespolyclonal and monoclonal antibodies, and monovalent and divalentfragments thereof. Furthermore, “antibody” includes chimeric antibodies,wholly synthetic antibodies, single chain antibodies, and fragmentsthereof. The antibody may be a human or nonhuman antibody. A nonhumanantibody may be humanized by recombinant methods to reduce itsimmunogenicity in man.

Antibodies are prepared according to conventional methodology.Monoclonal antibodies may be generated using the method of Kohler andMilstein (Nature, 256:495, 1975). To prepare monoclonal antibodiesuseful in the invention, a mouse or other appropriate host animal isimmunized at suitable intervals (e.g., twice-weekly, weekly,twice-monthly or monthly) with antigenic forms of APJ. The animal may beadministered a final “boost” of antigen within one week of sacrifice. Itis often desirable to use an immunologic adjuvant during immunization.Suitable immunologic adjuvants include Freund's complete adjuvant,Freund's incomplete adjuvant, alum, Ribi adjuvant, Hunter's Titermax,saponin adjuvants such as QS21 or Quil A, or CpG-containingimmunostimulatory oligonucleotides. Other suitable adjuvants arewell-known in the field. The animals may be immunized by subcutaneous,intraperitoneal, intramuscular, intravenous, intranasal or other routes.A given animal may be immunized with multiple forms of the antigen bymultiple routes.

Briefly, the antigen may be provided as synthetic peptides correspondingto antigenic regions of interest in APJ. Following the immunizationregimen, lymphocytes are isolated from the spleen, lymph node or otherorgan of the animal and fused with a suitable myeloma cell line using anagent such as polyethylene glycol to form a hydridoma. Following fusion,cells are placed in media permissive for growth of hybridomas but notthe fusion partners using standard methods, as described (Coding,Monoclonal Antibodies: Principles and Practice: Production andApplication of Monoclonal Antibodies in Cell Biology, Biochemistry andImmunology, 3rd edition, Academic Press, New York, 1996). Followingculture of the hybridomas, cell supernatants are analyzed for thepresence of antibodies of the desired specificity, i.e., thatselectively bind the antigen. Suitable analytical techniques includeELISA, flow cytometry, immunoprecipitation, and western blotting. Otherscreening techniques are well-known in the field. Preferred techniquesare those that confirm binding of antibodies to conformationally intact,natively folded antigen, such as non-denaturing ELISA, flow cytometry,and immunoprecipitation.

Significantly, as is well-known in the art, only a small portion of anantibody molecule, the paratope, is involved in the binding of theantibody to its epitope (see, in general, Clark, W. R. (1986) TheExperimental Foundations of Modern Immunology Wiley & Sons, Inc., NewYork; Roitt, I. (1991) Essential Immunology, 7th Ed., BlackwellScientific Publications, Oxford). The Fc′ and Fc regions, for example,are effectors of the complement cascade but are not involved in antigenbinding. An antibody from which the pFc′ region has been enzymaticallycleaved, or which has been produced without the pFc′ region, designatedan F(ab′)₂ fragment, retains both of the antigen binding sites of anintact antibody. Similarly, an antibody from which the Fc region hasbeen enzymatically cleaved, or which has been produced without the Fcregion, designated an Fab fragment, retains one of the antigen bindingsites of an intact antibody molecule. Proceeding further, Fab fragmentsconsist of a covalently bound antibody light chain and a portion of theantibody heavy chain denoted Fd. The Fd fragments are the majordeterminant of antibody specificity (a single Fd fragment may beassociated with up to ten different light chains without alteringantibody specificity) and Fd fragments retain epitope-binding ability inisolation.

Within the antigen-binding portion of an antibody, as is well-known inthe art, there are complementarity determining regions (CDRs), whichdirectly interact with the epitope of the antigen, and framework regions(FRs), which maintain the tertiary structure of the paratope (see, ingeneral, Clark, 1986; Roitt, 1991). In both the heavy chain Fd fragmentand the light chain of IgG immunoglobulins, there are four frameworkregions (FR1 through FR4) separated respectively by threecomplementarity determining regions (CDR1 through CDRS). The CDRs, andin particular the CDRS regions, and more particularly the heavy chainCDRS, are largely responsible for antibody specificity.

It is now well-established in the art that the non CDR regions of amammalian antibody may be replaced with similar regions of conspecificor heterospecific antibodies while retaining the epitopic specificity ofthe original antibody. This is most clearly manifested in thedevelopment and use of “humanized” antibodies in which non-human CDRsare covalently joined to human FR and/or Fc/pFc′ regions to produce afunctional antibody.

This invention provides in certain embodiments compositions and methodsthat include humanized forms of antibodies. As used herein, “humanized”describes antibodies wherein some, most or all of the amino acidsoutside the CDR regions are replaced with corresponding amino acidsderived from human immunoglobulin molecules. Methods of humanizationinclude, but are not limited to, those described in U.S. Pat. Nos.4,816,567, 5,225,539, 5,585,089, 5,693,761, 5,693,762 and 5,859,205,which are hereby incorporated by reference. The above U.S. Pat. Nos.5,585,089 and 5,693,761, and WO 90/07861 also propose four possiblecriteria which may used in designing the humanized antibodies. The firstproposal was that for an acceptor, use a framework from a particularhuman immunoglobulin that is unusually homologous to the donorimmunoglobulin to be humanized, or use a consensus framework from manyhuman antibodies. The second proposal was that if an amino acid in theframework of the human immunoglobulin is unusual and the donor aminoacid at that position is typical for human sequences, then the donoramino acid rather than the acceptor may be selected. The third proposalwas that in the positions immediately adjacent to the 3 CDRs in thehumanized immunoglobulin chain, the donor amino acid rather than theacceptor amino acid may be selected. The fourth proposal was to use thedonor amino acid reside at the framework positions at which the aminoacid is predicted to have a side chain atom within 3A of the CDRs in athree dimensional model of the antibody and is predicted to be capableof interacting with the CDRs. The above methods are merely illustrativeof some of the methods that one skilled in the art could employ to makehumanized antibodies. One of ordinary skill in the art will be familiarwith other methods for antibody humanization.

In one embodiment of the humanized forms of the antibodies, some, mostor all of the amino acids outside the CDR regions have been replacedwith amino acids from human immunoglobulin molecules but where some,most or all amino acids within one or more CDR regions are unchanged.Small additions, deletions, insertions, substitutions or modificationsof amino acids are permissible as long as they would not abrogate theability of the antibody to bind a given antigen. Suitable humanimmunoglobulin molecules would include IgG1, IgG2, IgG3, IgG4, IgA andIgM molecules. A “humanized” antibody retains a similar antigenicspecificity as the original antibody. However, using certain methods ofhumanization, the affinity and/or specificity of binding of the antibodymay be increased using methods of “directed evolution”, as described byWu et al.,/. Mol. Biol. 294:151, 1999, the contents of which areincorporated herein by reference.

Fully human monoclonal antibodies also can be prepared by immunizingmice transgenic for large portions of human immunoglobulin heavy andlight chain loci. See, e.g., U.S. Pat. Nos. 5,591,669, 5,598,369,5,545,806, 5,545,807, 6,150,584, and references cited therein, thecontents of which are incorporated herein by reference. These animalshave been genetically modified such that there is a functional deletionin the production of endogenous (e.g., murine) antibodies. The animalsare further modified to contain all or a portion of the human germ-lineimmunoglobulin gene locus such that immunization of these animals willresult in the production of fully human antibodies to the antigen ofinterest. Following immunization of these mice (e.g., XenoMouse(Abgenix), HuMAb mice (Medarex/GenPharm)), monoclonal antibodies can beprepared according to standard hybridoma technology. These monoclonalantibodies will have human immunoglobulin amino acid sequences andtherefore will not provoke human anti-mouse antibody (KAMA) responseswhen administered to humans.

In vitro methods also exist for producing human antibodies. Theseinclude phage display technology (U.S. Pat. Nos. 5,565,332 and5,573,905) and in vitro stimulation of human B cells (U.S. Pat. Nos.5,229,275 and 5,567,610). The contents of these patents are incorporatedherein by reference.

Thus, as will be apparent to one of ordinary skill in the art, thepresent invention also provides for F(ab) 2 Fab, Fv and Fd fragments;chimeric antibodies in which the Fc and/or FR and/or CDR1 and/or CDR2and/or light chain CDR3 regions have been replaced by homologous humanor non-human sequences; chimeric F(ab′)₂ fragment antibodies in whichthe FR and/or CDR1 and/or CDR2 and/or light chain CDR3 regions have beenreplaced by homologous human or non-human sequences; chimeric Fabfragment antibodies in which the FR and/or CDR1 and/or CDR2 and/or lightchain CDR3 regions have been replaced by homologous human or non-humansequences; and chimeric Fd fragment antibodies in which the FR and/orCDR1 and/or CDR2 regions have been replaced by homologous human ornon-human sequences. The present invention also includes so-calledsingle chain antibodies.

The various antibody molecules and fragments may derive from any of thecommonly known immunoglobulin classes, including but not limited to IgA,secretory IgA, IgE, IgG and IgM. IgG subclasses are also well known tothose in the art and include but are not limited to human IgG1, IgG2,IgG3 and IgG4.

In another embodiment, the antibody according to the invention is asingle domain antibody. The term “single domain antibody” (sdAb) or“VHH” refers to the single heavy chain variable domain of antibodies ofthe type that can be found in Camelid mammals which are naturally devoidof light chains. Such VHH are also called “Nanobody®”. According to theinvention, sdAb can particularly be llama sdAb.

In another embodiment the APJ receptor agonist is an aptamer.

Aptamers are a class of molecules that represents an alternative toantibodies in term of molecular recognition. Aptamers areoligonucleotide sequences with the capacity to recognize virtually anyclass of target molecules with high affinity and specificity. Suchligands may be isolated through Systematic Evolution of Ligands byEXponential enrichment (SELEX) of a random sequence library, asdescribed in Tuerk C. and Gold L., 1990. The random sequence library isobtainable by combinatorial chemical synthesis of DNA. In this library,each member is a linear oligomer, eventually chemically modified, of aunique sequence. Possible modifications, uses and advantages of thisclass of molecules have been reviewed in Jayasena S. D., 1999. Peptideaptamers consists of a conformationally constrained antibody variableregion displayed by a platform protein, such as E. coli Thioredoxin Athat are selected from combinatorial libraries by two hybrid methods(Colas et al., 1996). Then after raising aptamers directed against APJsas above described, the skilled man in the art can easily select thosepromoting APJ receptor function.

In another embodiment the APJ receptor agonist may consist in apolypeptide. Preferably, said polypeptide is the apelin itself. Morepreferably, the polypeptide is an apelin polypeptide.

The term “apelin” has its general meaning in the art and includesnaturally occurring apelin and function conservative variants andmodified forms thereof. The apelin can be from any source, but typicallyis a mammalian (e.g., human and non-human primate) apelin, and moreparticularly a human apelin. The sequence of apelin protein and nucleicacids for encoding such proteins are well known to those of skill in theart. Apelin is synthesized as 77-amino acid precursor and is found as adimer, stabilized by disulfide bridges (Lee D K, Saldivia V R, Nguyen T,Cheng R, George S R, O'Dowd B F. Modification of the terminal residue ofapelin-13 antagonizes its hypotensive action. Endocrinology. January146(1):231-6. 2005). The pre-apelin is converted by proteolytic cleavageto produce different C-terminal fragments, including apelin-36,apelin-17, apelin-13, and the post-translationally modified(Pyr¹)apelin-13, all are agonist to apelin receptor: APJ. The lack ofcysteine residues in these C-terminal fragments suggests that the maturepeptides are monomeric. It should be understood that, as those of skillin the art are aware of the sequence of these molecules, any apelinprotein or gene sequence variant may be used as long as it has theproperties of an apelin.

“Function conservative variants” are those in which a given amino acidresidue in a protein or enzyme has been changed without altering theoverall conformation and function of the polypeptide, including, but notlimited to, replacement of an amino acid with one having similarproperties (such as, for example, polarity, hydrogen bonding potential,acidic, basic, hydrophobic, aromatic, and the like). Amino acids otherthan those indicated as conserved may differ in a protein so that thepercent protein or amino acid sequence similarity between any twoproteins of similar function may vary and may be, for example, from 70%to 99% as determined according to an alignment scheme such as by theCluster Method, wherein similarity is based on the MEGALIGN algorithm. A“function-conservative variant” also includes a polypeptide which has atleast 60% amino acid identity as determined by BLAST or FASTAalgorithms, preferably at least 75%, most preferably at least 85%, andeven more preferably at least 90%, and which has the same orsubstantially similar properties or functions as the native or parentprotein to which it is compared.

According to the invention the term “apelin” polypeptide refers to anypolypeptide that comprises the apelin-13 C-terminal fragment.Accordingly, the term encompasses apelin itself or fragments thereofcomprising the apelin-17 or apelin-36 fragments.

In a particular embodiment, the apelin used according to the inventionis the (Pyr¹)apelin-13.

In specific embodiments, it is contemplated that apelin polypeptidesused in the therapeutic methods of the present invention may be modifiedin order to improve their therapeutic efficacy. Such modification oftherapeutic compounds may be used to decrease toxicity, increasecirculatory time, or modify biodistribution. For example, the toxicityof potentially important therapeutic compounds can be decreasedsignificantly by combination with a variety of drug carrier vehiclesthat modify biodistribution.

A strategy for improving drug viability is the utilization ofwater-soluble polymers. Various water-soluble polymers have been shownto modify biodistribution, improve the mode of cellular uptake, changethe permeability through physiological barriers; and modify the rate ofclearance from the body. To achieve either a targeting orsustained-release effect, water-soluble polymers have been synthesizedthat contain drug moieties as terminal groups, as part of the backbone,or as pendent groups on the polymer chain.

Polyethylene glycol (PEG) has been widely used as a drug carrier, givenits high degree of biocompatibility and ease of modification. Attachmentto various drugs, proteins, and liposomes has been shown to improveresidence time and decrease toxicity. PEG can be coupled to activeagents through the hydroxyl groups at the ends of the chain and viaother chemical methods; however, PEG itself is limited to at most twoactive agents per molecule. In a different approach, copolymers of PEGand amino acids were explored as novel biomaterials which would retainthe biocompatibility properties of PEG, but which would have the addedadvantage of numerous attachment points per molecule (providing greaterdrug loading), and which could be synthetically designed to suit avariety of applications.

Those of skill in the art are aware of PEGylation techniques for theeffective modification of drugs. For example, drug delivery polymersthat consist of alternating polymers of PEG and tri-functional monomerssuch as lysine have been used by VectraMed (Plainsboro, N.J.). The PEGchains (typically 2000 daltons or less) are linked to the a- and e-aminogroups of lysine through stable urethane linkages. Such copolymersretain the desirable properties of PEG, while providing reactive pendentgroups (the carboxylic acid groups of lysine) at strictly controlled andpredetermined intervals along the polymer chain. The reactive pendentgroups can be used for derivatization, cross-linking, or conjugationwith other molecules. These polymers are useful in producing stable,long-circulating pro-drugs by varying the molecular weight of thepolymer, the molecular weight of the PEG segments, and the cleavablelinkage between the drug and the polymer. The molecular weight of thePEG segments affects the spacing of the drug/linking group complex andthe amount of drug per molecular weight of conjugate (smaller PEGsegments provides greater drug loading). In general, increasing theoverall molecular weight of the block co-polymer conjugate will increasethe circulatory half-life of the conjugate. Nevertheless, the conjugatemust either be readily degradable or have a molecular weight below thethreshold-limiting glomular filtration (e.g., less than 45 kDa).

In addition, to the polymer backbone being important in maintainingcirculatory half-life, and biodistribution, linkers may be used tomaintain the therapeutic agent in a pro-drug form until released fromthe backbone polymer by a specific trigger, typically enzyme activity inthe targeted tissue. For example, this type of tissue activated drugdelivery is particularly useful where delivery to a specific site ofbiodistribution is required and the therapeutic agent is released at ornear the site of pathology. Linking group libraries for use in activateddrug delivery are known to those of skill in the art and may be based onenzyme kinetics, prevalence of active enzyme, and cleavage specificityof the selected disease-specific enzymes (see e.g., technologies ofestablished by VectraMed, Plainsboro, N.J.). Such linkers may be used inmodifying the apelin polypeptides described herein for therapeuticdelivery.

According to the invention, apelin polypeptides may be produced byconventional automated peptide synthesis methods or by recombinantexpression. General principles for designing and making proteins arewell known to those of skill in the art.

Apelin polypeptides of the invention may be synthesized in solution oron a solid support in accordance with conventional techniques. Variousautomatic synthesizers are commercially available and can be used inaccordance with known protocols. Apelin polypeptides of the inventionmay also be synthesized by solid-phase technology employing an exemplarypeptide synthesizer such as a Model 433A from Applied Biosystems Inc.The purity of any given protein; generated through automated peptidesynthesis or through recombinant methods may be determined using reversephase HPLC analysis. Chemical authenticity of each peptide may beestablished by any method well known to those of skill in the art.

As an alternative to automated peptide synthesis, recombinant DNAtechnology may be employed wherein a nucleotide sequence which encodes aprotein of choice is inserted into an expression vector, transformed ortransfected into an appropriate host cell and cultivated underconditions suitable for expression as described herein below.Recombinant methods are especially preferred for producing longerpolypeptides.

A variety of expression vector/host systems may be utilized to containand express the peptide or protein coding sequence. These include butare not limited to microorganisms such as bacteria transformed withrecombinant bacteriophage, plasmid or cosmid DNA expression vectors;yeast transformed with yeast expression vectors; insect cell systemsinfected with virus expression vectors (e.g., baculovirus); plant cellsystems transfected with virus expression vectors (e.g., cauliflowermosaic virus, CaMV; tobacco mosaic virus, TMV) or transformed withbacterial expression vectors (e.g., Ti or pBR322 plasmid); or animalcell systems. Those of skill in the art are aware of various techniquesfor optimizing mammalian expression of proteins. Mammalian cells thatare useful in recombinant protein productions include but are notlimited to VERO cells, HeLa cells, Chinese hamster ovary (CHO) celllines, COS cells (such as COS-7), W138, BHK, HepG2, 3T3, RIN, MDCK,A549, PC12, K562 and 293 cells. Exemplary protocols for the recombinantexpression of the peptide substrates or fusion polypeptides in bacteria,yeast and other invertebrates are known to those of skill in the art anda briefly described herein below. Mammalian host systems for theexpression of recombinant proteins also are well known to those of skillin the art. Host cell strains may be chosen for a particular ability toprocess the expressed protein or produce certain post-translationmodifications that will be useful in providing protein activity. Suchmodifications of the polypeptide include, but are not limited to,acetylation, carboxylation, glycosylation, phosphorylation, lipidationand acylation. Post-translational processing which cleaves a “prepro”form of the protein may also be important for correct insertion, foldingand/or function. Different host cells such as CHO, HeLa, MDCK, 293,WI38, and the like have specific cellular machinery and characteristicmechanisms for such post-translational activities and may be chosen toensure the correct modification and processing of the introduced,foreign protein.

In the recombinant production of the apelin polypeptides of theinvention, it would be necessary to employ vectors comprisingpolynucleotide molecules for encoding the apelin-derived proteins.Methods of preparing such vectors as well as producing host cellstransformed with such vectors are well known to those skilled in theart. The polynucleotide molecules used in such an endeavor may be joinedto a vector, which generally includes a selectable marker and an originof replication, for propagation in a host. These elements of theexpression constructs are well known to those of skill in the art.Generally, the expression vectors include DNA encoding the given proteinbeing operably linked to suitable transcriptional or translationalregulatory sequences, such as those derived from a mammalian, microbial,viral, or insect genes. Examples of regulatory sequences includetranscriptional promoters, operators, or enhancers, mRNA ribosomalbinding sites, and appropriate sequences which control transcription andtranslation.

The terms “expression vector,” “expression construct” or “expressioncassette” are used interchangeably throughout this specification and aremeant to include any type of genetic construct containing a nucleic acidcoding for a gene product in which part or all of the nucleic acidencoding sequence is capable of being transcribed.

The choice of a suitable expression vector for expression of thepeptides or polypeptides of the invention will of course depend upon thespecific host cell to be used, and is within the skill of the ordinaryartisan. Methods for the construction of mammalian expression vectorsare disclosed, for example, in EP-A-0367566; and WO 91/18982.

In general, the vectors useful in the invention include, but are notlimited to, plasmids, phagemids, viruses, other vehicles derived fromviral or bacterial sources that have been manipulated by the insertionor incorporation of the antisense oligonucleotide, siRNA, shRNA orribozyme nucleic acid sequences. Viral vectors are a preferred type ofvector and include, but are not limited to nucleic acid sequences fromthe following viruses: retrovirus, such as moloney murine leukemiavirus, harvey murine sarcoma virus, murine mammary tumor virus, and roussarcoma virus; adenovirus, adeno-associated virus; SV40-type viruses;polyoma viruses; Epstein-Barr viruses; papilloma viruses; herpes virus;vaccinia virus; polio virus; and RNA virus such as a retrovirus. One canreadily employ other vectors not named but known to the art.

Preferred viral vectors are based on non-cytopathic eukaryotic virusesin which non-essential genes have been replaced with the gene ofinterest. Non-cytopathic viruses include retroviruses (e.g.,lentivirus), the life cycle of which involves reverse transcription ofgenomic viral RNA into DNA with subsequent proviral integration intohost cellular DNA. Retroviruses have been approved for human genetherapy trials. Most useful are those retroviruses that arereplication-deficient (i.e., capable of directing synthesis of thedesired proteins, but incapable of manufacturing an infectiousparticle). Such genetically altered retroviral expression vectors havegeneral utility for the high-efficiency transduction of genes in vivo.Standard protocols for producing replication-deficient retroviruses(including the steps of incorporation of exogenous genetic material intoa plasmid, transfection of a packaging cell lined with plasmid,production of recombinant retroviruses by the packaging cell line,collection of viral particles from tissue culture media, and infectionof the target cells with viral particles) are well known in the art.

Preferred viruses for certain applications are the adenoviruses andadeno-associated (AAV) viruses, which are double-stranded DNA virusesthat have already been approved for human use in gene therapy. Actually12 different AAV serotypes (AAV1 to 12) are known, each with differenttissue tropisms. Recombinant AAV are derived from the dependentparvovirus AAV2. The adeno-associated virus type 1 to 12 can beengineered to be replication deficient and is capable of infecting awide range of cell types and species. It further has advantages such as,heat and lipid solvent stability; high transduction frequencies in cellsof diverse lineages, including hemopoietic cells; and lack ofsuperinfection inhibition thus allowing multiple series oftransductions. Reportedly, the adeno-associated virus can integrate intohuman cellular DNA in a site-specific manner, thereby minimizing thepossibility of insertional mutagenesis and variability of inserted geneexpression characteristic of retroviral infection. In addition,wild-type adeno-associated virus infections have been followed in tissueculture for greater than 100 passages in the absence of selectivepressure, implying that the adeno-associated virus genomic integrationis a relatively stable event. The adeno-associated virus can alsofunction in an extrachromosomal fashion.

Other vectors include plasmid vectors. Plasmid vectors have beenextensively described in the art and are well known to those of skill inthe art. In the last few years, plasmid vectors have been used as DNAvaccines for delivering antigen-encoding genes to cells in vivo. Theyare particularly advantageous for this because they do not have the samesafety concerns as with many of the viral vectors. These plasmids,however, having a promoter compatible with the host cell, can express apeptide from a gene operatively encoded within the plasmid. Somecommonly used plasmids include pBR322, pUC18, pUC19, pRC/CMV, SV40, andpBlueScript. Other plasmids are well known to those of ordinary skill inthe art. Additionally, plasmids may be custom designed using restrictionenzymes and ligation reactions to remove and add specific fragments ofDNA. Plasmids may be delivered by a variety of parenteral, mucosal andtopical routes. For example, the DNA plasmid can be injected byintramuscular, intradermal, subcutaneous, or other routes. It may alsobe administered by intranasal sprays or drops, rectal suppository andorally. It may also be administered into the epidermis or a mucosalsurface using a gene-gun. The plasmids may be given in an aqueoussolution, dried onto gold particles or in association with another DNAdelivery system including but not limited to liposomes, dendrimers,cochleate and microencapsulation.

Expression requires that appropriate signals be provided in the vectors,such as enhancers/promoters from both viral and mammalian sources thatmay be used to drive expression of the nucleic acids of interest in hostcells. Usually, the nucleic acid being expressed is undertranscriptional control of a promoter. A “promoter” refers to a DNAsequence recognized by the synthetic machinery of the cell, orintroduced synthetic machinery, required to initiate the specifictranscription of a gene. Nucleotide sequences are operably linked whenthe regulatory sequence functionally relates to the DNA encoding theprotein of interest (i.e., apelin, a variant and the like). Thus, apromoter nucleotide sequence is operably linked to a given DNA sequenceif the promoter nucleotide sequence directs the transcription of thesequence.

Similarly, the phrase “under transcriptional control” means that thepromoter is in the correct location and orientation in relation to thenucleic acid to control RNA polymerase initiation and expression of thegene. Any promoter that will drive the expression of the nucleic acidmay be used. The particular promoter employed to control the expressionof a nucleic acid sequence of interest is not believed to be important,so long as it is capable of directing the expression of the nucleic acidin the targeted cell. Thus, where a human cell is targeted, it ispreferable to position the nucleic acid coding region adjacent to andunder the control of a promoter that is capable of being expressed in ahuman cell. Generally speaking, such a promoter might include either ahuman or viral promoter. Common promoters include, e.g., the humancytomegalovirus (CMV) immediate early gene promoter, the SV40 earlypromoter, the Rous sarcoma virus long terminal repeat, [beta]-actin, ratinsulin promoter, the phosphoglycerol kinase promoter andglyceraldehyde-3-phosphate dehydrogenase promoter, all of which arepromoters well known and readily available to those of skill in the art,can be used to obtain high-level expression of the coding sequence ofinterest. The use of other viral or mammalian cellular or bacterialphage promoters which are well-known in the art to achieve expression ofa coding sequence of interest is contemplated as well, provided that thelevels of expression are sufficient to produce a recoverable yield ofprotein of interest. By employing a promoter with well known properties,the level and pattern of expression of the protein of interest followingtransfection or transformation can be optimized. Inducible promotersalso may be used.

Another regulatory element that is used in protein expression is anenhancer. These are genetic elements that increase transcription from apromoter located at a distant position on the same molecule of DNA.Where an expression construct employs a cDNA insert, one will typicallydesire to include a polyadenylation signal sequence to effect properpolyadenylation of the gene transcript. Any polyadenylation signalsequence recognized by cells of the selected transgenic animal speciesis suitable for the practice of the invention, such as human or bovinegrowth hormone and SV40 polyadenylation signals.

Other polypeptides that can be used as APJ receptor agonists includethose described in U.S. Pat. No. 6,492,324, in U.S. Pat. No. 7,635,751,in US 2010221255 or in US 2008182779.

In some embodiments, the APJ receptor agonist according to the inventionis an apelinomimetic.

As used herein, the term “apelinomimetics” denotes molecules which arefunctionally equivalent to apelin that is to say molecules which have atleast one of the biological activities of the apelin, such as, forexample, hypotensive effect of apelin or plasma glucose lowering ofapelin. In other words, “apelinomimetics” denotes molecules able tomimic/reproduce apelin effects.

Activities of apelinomimetics may be determined by any well known methodin the art. For example, the capacity of a molecule to be anapelinomimetic may be measured by the capacity to improve insulinsensitivity and/or to decrease blood glucose like the apelin. Forexample, a glucose tolerance test can be used (see for examplehttp://en.wikipedia.org/wiki/Glucose_tolerance_test).

In a further example, the ability of a substance to act as anapelinomimetics may be assessed through its ability to increase theGlucose Infusion Rate in vivo, during an hyperglycemic clamp procedurein the assay disclosed in the examples herein and otherwise described byDeFronzo R A et al., 1979.

A further object of the invention relates to pharmaceutical compositionscomprising an APJ receptor agonist for use in the treatment or theprevention of diabetes.

Typically, the APJ receptor agonist may be combined withpharmaceutically acceptable excipients, and optionally sustained-releasematrices, such as biodegradable polymers, to form therapeuticcompositions.

“Pharmaceutically” or “pharmaceutically acceptable” refer to molecularentities and compositions that do not produce an adverse, allergic orother untoward reaction when administered to a mammal, especially ahuman, as appropriate. A pharmaceutically acceptable carrier orexcipient refers to a non-toxic solid, semi-solid or liquid filler,diluent, encapsulating material or formulation auxiliary of any type.

In the pharmaceutical compositions of the present invention for oral,sublingual, subcutaneous, intramuscular, intravenous, transdermal, localor rectal administration, the active principle, alone or in combinationwith another active principle, can be administered in a unitadministration form, as a mixture with conventional pharmaceuticalsupports, to animals and human beings. Suitable unit administrationforms comprise oral-route forms such as tablets, gel capsules, powders,granules and oral suspensions or solutions, sublingual and buccaladministration forms, aerosols, implants, subcutaneous, transdermal,topical, intraperitoneal, intramuscular, intravenous, subdermal,transdermal, intrathecal and intranasal administration forms and rectaladministration forms.

Preferably, the pharmaceutical compositions contain vehicles which arepharmaceutically acceptable for a formulation capable of being injected.These may be in particular isotonic, sterile, saline solutions(monosodium or disodium phosphate, sodium, potassium, calcium ormagnesium chloride and the like or mixtures of such salts), or dry,especially freeze-dried compositions which upon addition, depending onthe case, of sterilized water or physiological saline, permit theconstitution of injectable solutions.

The pharmaceutical forms suitable for injectable use include sterileaqueous solutions or dispersions; formulations including sesame oil,peanut oil or aqueous propylene glycol; and sterile powders for theextemporaneous preparation of sterile injectable solutions ordispersions. In all cases, the form must be sterile and must be fluid tothe extent that easy syringability exists. It must be stable under theconditions of manufacture and storage and must be preserved against thecontaminating action of microorganisms, such as bacteria and fungi.

Solutions comprising compounds of the invention as free base orpharmacologically acceptable salts can be prepared in water suitablymixed with a surfactant, such as hydroxypropylcellulose. Dispersions canalso be prepared in glycerol, liquid polyethylene glycols, and mixturesthereof and in oils. Under ordinary conditions of storage and use, thesepreparations contain a preservative to prevent the growth ofmicroorganisms.

The APJ receptor agonist can be formulated into a composition in aneutral or salt form. Pharmaceutically acceptable salts include the acidaddition salts (formed with the free amino groups of the protein) andwhich are formed with inorganic acids such as, for example, hydrochloricor phosphoric acids, or such organic acids as acetic, oxalic, tartaric,mandelic, and the like. Salts formed with the free carboxyl groups canalso be derived from inorganic bases such as, for example, sodium,potassium, ammonium, calcium, or ferric hydroxides, and such organicbases as isopropylamine, trimethylamine, histidine, procaine and thelike.

The carrier can also be a solvent or dispersion medium containing, forexample, water, ethanol, polyol (for example, glycerol, propyleneglycol, and liquid polyethylene glycol, and the like), suitable mixturesthereof, and vegetables oils. The proper fluidity can be maintained, forexample, by the use of a coating, such as lecithin, by the maintenanceof the required particle size in the case of dispersion and by the useof surfactants. The prevention of the action of microorganisms can bebrought about by various antibacterial and antifungal agents, forexample, parabens, chlorobutanol, phenol, sorbic acid, thimerosal, andthe like. In many cases, it will be preferable to include isotonicagents, for example, sugars or sodium chloride. Prolonged absorption ofthe injectable compositions can be brought about by the use in thecompositions of agents delaying absorption, for example, aluminiummonostearate and gelatin.

Sterile injectable solutions are prepared by incorporating the activepolypeptides in the required amount in the appropriate solvent withseveral of the other ingredients enumerated above, as required, followedby filtered sterilization. Generally, dispersions are prepared byincorporating the various sterilized active ingredients into a sterilevehicle which contains the basic dispersion medium and the requiredother ingredients from those enumerated above. In the case of sterilepowders for the preparation of sterile injectable solutions, thepreferred methods of preparation are vacuum-drying and freeze-dryingtechniques which yield a powder of the active ingredient plus anyadditional desired ingredient from a previously sterile-filteredsolution thereof.

Upon formulation, solutions will be administered in a manner compatiblewith the dosage formulation and in such amount as is therapeuticallyeffective. The formulations are easily administered in a variety ofdosage forms, such as the type of injectable solutions described above,but drug release capsules and the like can also be employed.

For parenteral administration in an aqueous solution, for example, thesolution should be suitably buffered if necessary and the liquid diluentfirst rendered isotonic with sufficient saline or glucose. Theseparticular aqueous solutions are especially suitable for intravenous,intramuscular, subcutaneous and intraperitoneal administration. In thisconnection, sterile aqueous media which can be employed will be known tothose of skill in the art in light of the present disclosure. Somevariation in dosage will necessarily occur depending on the condition ofthe subject being treated. The person responsible for administrationwill, in any event, determine the appropriate dose for the individualsubject.

In addition to the compounds of the invention formulated for parenteraladministration, such as intravenous or intramuscular injection, otherpharmaceutically acceptable forms include, e.g. tablets or other solidsfor oral administration; liposomal formulations; time release capsules;and any other form currently used.

A further object of the invention relates to a method for screeningdrugs for the prevention and treatment of diabetes comprising the stepsconsisting of testing a plurality of compounds for their ability to bean APJ receptor agonist, and selecting positively the compounds that areAPJ receptor agonists.

Methods for determining the agonistic activities of a compound for APJreceptors are described above.

Another object of the invention relates to a method for treatingdiabetes comprising administering to a subject in need thereof atherapeutically effective amount of an APJ receptor agonist as describedabove.

In still a particular object, the APJ receptor agonist is the apelin.

In another object, the apelin is the (Pyr¹)apelin-13.

As used herein, the term “treating” or “treatment”, denotes reversing,alleviating, inhibiting the progress of, or preventing the disorder orcondition to which such term applies, or reversing, alleviating,inhibiting the progress of, or preventing one or more symptoms of thedisorder or condition to which such term applies.

Determination of a therapeutically effective amount is well within thecapability of those skilled in the art. For any preparation used in themethods of the invention the therapeutically effective amount or dosecan be estimated initially in an animal model, such as a diabetes micemodel to achieve a desired concentration. Preferably, the effectiveamount of an APJ receptor agonist being administered to a human subjectranges between 10 nmol/kg to 150 nmol/kg per day.

In a particular embodiment, the dose administrated to the subject perday may be 10 nmol/kg, 11 nmol/kg, 12 nmol/kg, 13 nmol/kg, 14 nmol/kg,15 nmol/kg, 16 nmol/kg, 17 nmol/kg, 18 nmol/kgv, 19 nmol/kg, 20 nmol/kg21 nmol/kg, 22 nmol/kg, 23 nmol/kg, 24 nmol/kg, 25 nmol/kg, 26 nmol/kg,27 nmol/kg, 28 nmol/kg, 29 nmol/kg, 30 nmol/kg, 31 nmol/kg, 32 nmol/kg,34 nmol/kg, 35 nmol/kg, 36 nmol/kg, 37 nmol/kg, 38 nmol/kg, 39 nmol/kg,40 nmol/kg, 41 nmol/kg, 42 nmol/kg, 43 nmol/kg, 44 nmol/kg, 45 nmol/kg,46 nmol/kg, 47 nmol/kg, 48 nmol/kg, 49 nmol/kg, 50 nmol/kg 51 nmol/kg 52nmol/kg, 53 nmol/kg, 54 nmol/kg, 55 nmol/kg, 56 nmol/kg, 57 nmol/kg, 58nmol/kg, 59 nmol/kg or 60 nmol/kg, 61 nmol/kg, 62 nmol/kg, 63 nmol/kg,64 nmol/kg, 65 nmol/kg, 66 nmol/kg, 67 nmol/kg, 68 nmol/kg, 69 nmol/kg,70 nmol/kg, 71 nmol/kg, 72 nmol/kg, 73 nmol/kg, 74 nmol/kg, 75 nmol/kg,76 nmol/kg, 77 nmol/kg, 78 nmol/kg, 79 nmol/kg, 80 nmol/kg, 81 nmol/kg,82 nmol/kg, 83 nmol/kg, 84 nmol/kg, 85 nmol/kg, 86 nmol/kg, 87 nmol/kg,88 nmol/kg, 89 nmol/kg, 90 nmol/kg, 91 nmol/kg, 92 nmol/kg, 93 nmol/kg,94 nmol/kg, 95 nmol/kg, 96 nmol/kg, 97 nmol/kg, 98 nmol/kg, 99 nmol/kg,100 nmol/kg, 101 nmol/kg, 102 nmol/kg, 103 nmol/kg, 104 nmol/kg, 105nmol/kg, 106 nmol/kg, 107 nmol/kg, 108 nmol/kg, 109 nmol/kg, 110nmol/kg, 111 nmol/kg, 112 nmol/kg, 113 nmol/kg, 114 nmol/kg, 115nmol/kg, 116 nmol/kg, 117 nmol/kg, 118 nmol/kg, 119 nmol/kg, 120nmol/kg, 121 nmol/kg, 122 nmol/kg, 123 nmol/kg, 124 nmol/kg, 125nmol/kg, 126 nmol/kg, 127 nmol/kg, 128 nmol/kg, 129 nmol/kg, 130nmol/kg, 131 nmol/kg, 132 nmol/kg, 133 nmol/kg, 134 nmol/kg, 135nmol/kg, 136 nmol/kg, 137 nmol/kg, 138 nmol/kg, 139 nmol/kg, 140nmol/kg, 141 nmol/kg, 142 nmol/kg, 143 nmol/kg, 144 nmol/kg, 145nmol/kg, 146 nmol/kg, 147 nmol/kg, 148 nmol/kg, 149 nmol/kg, 150nmol/kg, 151 nmol/kg, 152 nmol/kg, 153 nmol/kg, 154 nmol/kg, 155nmol/kg, 156 nmol/kg, 157 nmol/kg, 158 nmol/kg, 159 nmol/kg, 160nmol/kg, 161 nmol/kg, 162 nmol/kg, 163 nmol/kg, 164 nmol/kg, 165nmol/kg, 166 nmol/kg, 167 nmol/kg, 168 nmol/kg, 169 nmol/kg, 170nmol/kg, 171 nmol/kg, 172 nmol/kg, 173 nmol/kg, 174 nmol/kg, 175nmol/kg, 176 nmol/kg, 177 nmol/kg, 178 nmol/kg, 179 nmol/kg, 180nmol/kg, 181 nmol/kg, 182 nmol/kg, 183 nmol/kg, 184 nmol/kg, 185nmol/kg, 186 nmol/kg, 187 nmol/kg, 188 nmol/kg, 189 nmol/kg, 190nmol/kg, 191 nmol/kg, 192 nmol/kg, 193 nmol/kg, 194 nmol/kg, 195nmol/kg, 196 nmol/kg, 197 nmol/kg, 198 nmol/kg, 199 nmol/kg and 200nmol/kg.

In some embodiments, the daily dose administered to the subject rangesfrom 10 nmol/kg to 150 nmol/kg and may be any dose ranging from 10nmol/kg to 200 nmol/kg that is listed above.

In some embodiments, the daily dose administered to the subject rangesfrom 10 nmol/kg to 150 nmol/kg and may be any dose ranging from 10nmol/kg to 150 nmol/kg that is listed above.

In some embodiments, the daily dose administered to the subject rangesfrom 10 nmol/kg to 60 nmol/kg and may be any dose ranging from 10nmol/kg to 60 nmol/kg that is listed above.

In some embodiments, the daily dose administered to the subject rangesfrom 20 nmol/kg to 40 nmol/kg and may be any dose ranging from 20nmol/kg to 40 nmol/kg that is listed above.

In some embodiments, the daily dose administered to the subject is about30 nmol/kg, for example is 30 nmol/kg.

In some embodiments, the said APJ receptor agonist, e.g. apelin or(Pyr¹)apelin-13, is administered by the parenteral route, e.g. theintravenous route.

In the embodiments wherein the said APJ receptor agonist, e.g. apelin or(Pyr¹)apelin-13, is administered by the parenteral route, the daily dosemay be administered by perfusing the said subject during a period oftime ranging from 30 minutes to 6 hours.

In the embodiments wherein the said APJ receptor agonist, e.g. apelin or(Pyr¹)apelin-13, is administered by the parenteral route, the daily dosemay be administered by perfusing the said subject during a period oftime ranging from 60 minutes to 4 hours.

In the embodiments wherein the said APJ receptor agonist, e.g. apelin or(Pyr¹)apelin-13, is administered by the parenteral route, the daily dosemay be administered by perfusing the said subject during a period oftime ranging from 1.5 hours to 2.5 hours.

In the embodiments wherein the said APJ receptor agonist, e.g. apelin or(Pyr¹)apelin-13, is administered by the parenteral route, the daily dosemay be administered by perfusing the said subject during a period of 2hours.

In another particular embodiment, the dose administrated to the subjectmay be one time, two times, three times or four times per day, every twodays, every three days, every four days, every five days, every sixdays, every seven days, every eight days, every nine days or every tendays.

In one embodiment the APJ receptor agonist, e.g. apelin or(Pyr¹)apelin-13, is administered by in a chronic way.

Accordingly, in another aspect, the invention also relates to akit-of-part that is suitable for use in the prevention or treatment ofdiabetes comprising an APJ receptor agonist and an anti-diabetic drug.

Thus, in one embodiment, the invention relates to (i) an APJ receptoragonist, as defined above, and (ii) at least one anti-diabetic drug,each of (i) and (ii) as a combined preparation for simultaneous,separate or sequential use in the treatment of diabetes.

As used herein, the term “anti-diabetic drug” refers to any compound,natural or synthetic, which can reduce glucose levels in the blood andtherefore is useful for preventing or treating diabetes. Typically,anti-diabetic drugs encompass (1) insulin as well as insulin analogs(for instance insulin lispro marketed by Eli Lilly as “Humalog”, insulinaspart marketed by Novo Nordisk or insulin glulisine marketed bySanofi-Aventis) or variants, (2) agents that increase the amount ofinsulin secreted by the pancreas (e.g. glucagon-like peptide-1 (GLP-1)receptor agonists, DPP-4 inhibitors, and sulfonylureas) (3) agents thatincrease the sensitivity of target organs to insulin (e.g. biguanidesand thiazolidinediones), and (4) agents that decrease the rate at whichglucose is absorbed from the gastrointestinal tract (e.g.alpha-glucosidase inhibitors).

In one particular embodiment, the anti-diabetic drug is insulin. Humaninsulin is a 51 amino acid peptide hormone produced in the islets ofLangerhans in the pancreas.

In another particular embodiment, the anti-diabetic drug is an insulinanalog or variant.

Human insulin has three primary amino groups: the N-terminal group ofthe A-chain and of the B-chain and the ε-amino group of LysB29. Severalinsulin analogs or variants which are substituted in one or more ofthese groups are known in the prior art as described in WO2007/074133.Exemplary insulin analogs that are contemplated by the invention includeinsulin modified at amino acid position 29 of the native human insulin Bchain and optionally at other positions. For instance, a preferredanalog of insulin is insulin lispro marketed by Eli Lilly as “Humalog”and described in U.S. Pat. No. 5,514,646. Such insulin analog is onewherein B28 is lysine and B29 is proline, i.e., an inversion of thenative human insulin amino acid sequence at positions 28 and 29 of theB-chain.

The insulin analogs of this invention can be prepared by any of avariety of recognized peptide synthesis techniques including classical(solution) methods, solid-phase methods, semi synthetic methods and themore recently available recombinant DNA methods.

In one particular embodiment, the anti-diabetic drug is a glucagon-likepeptide-1 (GLP-1) receptor agonist.

Exemplary GLP-1 receptor agonists that are contemplated by the inventioninclude but are not limited to exenatide or specific formulationsthereof, as described, for example, in WO2008061355, WO2009080024,WO2009080032, liraglutide, taspoglutide (R-1583), albiglutide,lixisenatide or those which have been disclosed in WO 98/08871,WO2005027978, WO2006037811, WO2006037810 by Novo Nordisk A/S, in WO01/04156 by Zealand or in WO 00/34331 by Beaufour-Ipsen, pramlintideacetate (Symlin; Amylin Pharmaceuticals), inhalable GLP-1 (MKC-253 fromMannKind) AVE-0010, BIM-51077 (R-1583, ITM-077), PC-DAC:exendin-4 (anexendin-4 analog which is bonded covalently to recombinant humanalbumin), biotinylated exendin (WO2009107900), a specific formulation ofexendin-4 as described in US2009238879, CVX-73, CVX-98 and CVx-96 (GLP-1analogs which are bonded covalently to a monoclonal antibody which hasspecific binding sites for the GLP-1 peptide), CNTO-736 (a GLP-1 analogwhich is bonded to a domain which includes the Fc portion of anantibody), PGC-GLP-1 (GLP-1 bonded to a nanocarrier), agonists ormodulators, as described, for example, in D. Chen et al., Proc. Natl.Acad. Sci. USA 104 (2007) 943, those as described in WO2006124529,WO2007124461, WO2008062457, WO2008082274, WO2008101017, WO2008081418,WO2008112939, WO2008112941, WO2008113601, WO2008116294, WO2008116648,WO2008119238, WO2008148839, US2008299096, WO2008152403, WO2009030738,WO2009030771, WO2009030774, WO2009035540, WO2009058734, WO2009111700,WO2009125424, WO2009129696, WO2009149148, peptides, for exampleobinepitide (TM-30338), orally active GLP-1 analogs (e.g. NN9924 fromNovo Nordisk), amylin receptor agonists, as described, for example, inWO2007104789, WO2009034119, analogs of the human GLP-1, as described inWO2007120899, WO2008022015, WO2008056726, chimeric pegylated peptidescontaining both GLP-1 and glucagon residues, as described, for example,in WO2008101017, WO2009155257, WO2009155258, glycosylated GLP-1derivatives as described in WO2009153960, and orally active hypoglycemicingredients.

In a particular embodiment, the GLP-1 receptor agonist is exendin-4 orexenatide.

Exendin-4 is described in the U.S. Pat. No. 5,424,286 and is a hormonefound in the saliva of the Gila monster which displays biologicalproperties similar to human glucagon-like peptide-1 (GLP-1), a regulatorof glucose metabolism and insulin secretion.

Exenatide is a 39-amino-acid peptide and a synthetic version ofexendin-4, which enhances glucose-dependent insulin secretion by thepancreatic n-cell and suppresses inappropriately elevated glucagonsecretion.

In another embodiment, the GLP-1 receptor agonist is liraglutide.

In another particular embodiment, the anti-diabetic drug is an inhibitorof dipeptidyl peptidase-IV (DDP-4).

Exemplary inhibitors of DDP-4 that are contemplated by the inventioninclude but are not limited to vildagliptin (LAF-237), sitagliptin(MK-0431), sitagliptin phosphate, saxagliptin (BMS-477118), GSK-823093,PSN-9301, SYR-322, SYR-619, TA-6666, TS-021, GRC-8200 (melogliptin),GW-825964X, KRP-104, DP-893, ABT-341, ABT-279 or another salt thereof,S-40010, S-40755, PF-00734200, BI-1356, PHX-1149, DSP-7238, alogliptinbenzoate, linagliptin, melogliptin, carmegliptin, or those compounds asdescribed in WO2003074500, WO2003106456, WO2004037169, WO200450658,WO2005037828, WO2005058901, WO2005012312, WO2005/012308, WO2006039325,WO2006058064, WO2006015691, WO2006015701, WO2006015699, WO2006015700,WO2006018117, WO2006099943, WO2006099941, JP2006160733, WO2006071752,WO2006065826, WO2006078676, WO2006073167, WO2006068163, WO2006085685,WO2006090915, WO2006104356, WO2006127530, WO2006111261, US2006890898,US2006803357, US2006303661, WO2007015767 (LY-2463665), WO2007024993,WO2007029086, WO2007063928, WO2007070434, WO2007071738, WO2007071576,WO2007077508, WO2007087231, WO2007097931, WO2007099385, WO2007100374,WO2007112347, WO2007112669, WO2007113226, WO2007113634, WO2007115821,WO2007116092, US2007259900, EP1852108, US2007270492, WO2007126745,WO2007136603, WO2007142253, WO2007148185, WO2008017670, US2008051452,WO2008027273, WO2008028662, WO2008029217, JP2008031064, JP2008063256,WO2008033851, WO2008040974, WO2008040995, WO2008060488, WO2008064107,WO2008066070, WO2008077597, JP2008156318, WO2008087560, WO2008089636,WO2008093960, WO2008096841, WO2008101953, WO2008118848, WO2008119005,WO2008119208, WO2008120813, WO2008121506, WO2008130151, WO2008131149,WO2009003681, WO2009014676, WO2009025784, WO2009027276, WO2009037719,WO2009068531, WO2009070314, WO2009065298, WO2009082134, WO2009082881,WO2009084497, WO2009093269, WO2009099171, WO2009099172, WO2009111239,WO2009113423, WO2009116067, US2009247532, WO2010000469, WO2010015664.

In a particular embodiment, the inhibitor of DDP-4 is sitagliptin.

It should be further noted that the inhibitor of DDP-4 may beadministered in combination with metformin hydrochloride (e.g.Janumet(R), a solid combination of sitagliptin phosphate with metforminhydrochloride or Eucreas(R), a solid combination of vildagliptin withmetformin hydrochloride).

In still another particular embodiment, the anti-diabetic drug is aGPR40 receptor agonist.

Exemplary of a GPR40 receptor agonists that are contemplated by theinvention include but are not limited to those described, for example,in WO2007013689, WO2007033002, WO2007106469, US2007265332, WO2007123225,WO2007131619, WO2007131620, WO2007131621, US2007265332, WO2007131622,WO2007136572, WO2008001931, WO2008030520, WO2008030618, WO2008054674,WO2008054675, WO2008066097, US2008176912, WO2008130514, WO2009038204,WO2009039942, WO2009039943, WO2009048527, WO2009054479, WO2009058237,WO2009111056, WO2010012650, WO2011161030, WO2012004269, WO2012010413.

In a particular embodiment, the GPR40 receptor agonist is TAK-875 or AMG837.

In a further particular embodiment, the anti-diabetic drug is athiazolidinedione, for example troglitazone, ciglitazone, pioglitazone,rosiglitazone or the compounds disclosed in WO 97/41097 by Dr. Reddy'sResearch Foundation, especially5-[[4-[(3,4-dihydro-3-methyl-4-oxo-2-quinazolinylmethoxy]-phenyl]methyl]-2,4-thiazolidinedione.

In a further particular embodiment, the anti-diabetic drug is abiguanide, for example metformin or one of its salts.

Other anti-diabetic drugs that are contemplated by the invention includebut are not limited to those described, for example, in US 2012/0004166.

The present invention also relates to a method for preventing ortreating diabetes comprising administering to a patient in need thereofa kit-of-part comprising an APJ receptor agonist and an anti-diabeticdrug.

The present invention further relates to the use of an APJ receptoragonist for enhancing the clinical efficacy of an anti-diabetic drug. Asused herein, the term “enhancing the clinical efficacy” refers to animprovement of the anti-inflammatory action and/or preserving pancreaticβ-cell viability and function.

The invention will be further illustrated by the following figures andexamples. However, these examples and figures should not be interpretedin any way as limiting the scope of the present invention.

EXAMPLES Example 1: Effect of Apelin on Insulin Sensitivity: Proof ofConcept in Healthy Volunteers

Material & Methods

It will be described below the clinical protocol conceived for assessingthe therapeutic effectiveness of a pharmaceutical composition disclosedin the present specification.

Type of Trial

This trial is a Phase 1, exploratory, monocentric, placebo-controlled,double blinded, crossover study.

Trial Population

Inclusion Criteria

Men aged 18 to 40.

BMI between 25 and 30 Kg/m² (limits excluded).

Without any known chronic disease and any ongoing drug therapy (no drugsin the 30 days preceding the inclusion visit).

Non-pathological electrocardiogram.

Resting heart rate between 50 and 80 beats per minute.

Complete Blood Count (CBC) with no significant anomaly of view of theinvestigator.

Liver function tests without clinically significant anomaly of view ofthe investigator.

Renal function tests without clinically significant anomaly of view ofthe investigator.

Serum electrolytes without clinically significant anomaly of view of theinvestigator.

Fasting blood glucose lower than 110 mg/dl.

HbAlc in the normal range (4-6%).

Good peripheral venous network (forearm and back of the hand).

Volunteer allowing his blood samples being stored in a serum bank.

Sedentary person or practicing an occasional physical activity.

Being able to sign an informed consent.

Affiliated to French National Social Insurance.

Non-Inclusion Criteria

Risk factors, treatment or electrocardiogram as recommended by ICH E14“Clinical Evaluation of QT/QTc Interval Prolongation and ProarrhythmicPotential for Non-Antiarrhythmic Drugs”

-   -   Repeated measurement of QTc>450 ms    -   TdP risk factor: myocardial infarction, hypokalemia, family        history of long QT syndrome

Personal history of cancer.

Positive HIV serology.

Positive Hepatitis B serology.

Positive Hepatitis C serology.

Cognitive impairment or mental illness (at the decision of theinvestigator).

Chronic excessive alcohol consumption (consumption>30 g/day or 210g/week).

Person under judicial protection or legal guardianship.

Subject with a blood pressure greater than 140/90 mmHg.

Smoking>10 cig/day and cannot be interrupted for 24 hours.

Subject into exclusion period from another protocol.

Trial Design

We assessed the influence of intravenous (pyr1)-Apelin-13administrations on insulin sensitivity using the hyperinsulinemiceuglycemic clamp technique developed by DeFronzo et al., 1979.

Two groups of 8 male, overweighed (BMI 25-30 kg/m²) healthy volunteerswere included in this study. A single 2 hours continuous intravenous(pyr1)-Apelin-13 infusion was administered to each volunteer.

The first 8 volunteers were included in the low dose group. They wereperfused with a 9 nmol/kg (pyr1)-Apelin-13 dose.

The study monitoring committee then reviewed the risks with regard tosafety data observed in the first 8 volunteers and any publishedinformation likely to cause a change in the estimate of the risks. Theinclusion of the next 8 volunteers was allowed after writtenauthorization of the study monitoring committee.

The next 8 volunteers were included in the high dose group. They wereperfused with a 30 nmol/kg (pyr1)-Apelin-13 dose.

Each volunteer underwent two clamps spaced by 7 to 21 days: a referenceclamp during which a placebo solution (perfusion solution) was perfusedand an “Apelin” clamp during which a (pyr1)-Apelin-13 infusion wasperfused. The sequence of administration of the tested products (placeboor apelin) was randomly determined and double blinded.

The clinical study included four visits: V1: inclusion visit V2: firstclamp V3: second clamp V4 end of study visit.

Flow Chart

Inclusion V1 Clamp 1 V2 Clamp 2 V3 End of study V4 (3 to 30 days (V1 + 3to 15 (V2 + 7 to 21 (V3 + 7 to 15 Information after information) days)days) days) Visit type Phone call Medical consultation One-dayhospitalisatio One-day hospitalisation Medical consultation Witteninformation Sent ✓ Informed consent ✓ Clinical examination ✓ ✓ ✓ ✓ Bloodtest ✓ ✓ ✓ ✓ Physical examination ✓ ✓ ✓ ✓ Clamp ✓ ✓ Placebo infusionAccording to randomisation Apelin infusion According to randomisationAdverse events ✓ ✓ ✓

Euglycemic Hyperinsulinemic Clamp Technique

-   -   Insulin (Actrapid®, NovoNordisk, Copenhagen, Denmark) was        perfused for 4 hours at a constant supra-physiological rate (1        mU·Kg-1.min-1) resulting in the complete inhibition of hepatic        glucose production.    -   Blood glucose level was measured every 5 min and maintained for        4 hours at a constant physiological value (5 mmol/1) adapting        the rate of infusion of a 20% glucose solution. The Glucose        infusion rate (GIR) was the main evaluation criterion, and was        reported on the case report form each 5 min.    -   A first steady state was reached from the 90th to the 120th min,        reflecting the “basal” insulin sensitivity of peripheral tissues        of the volunteer.    -   From the 120th min to 240th min, a continuous perfusion of the        investigational product (Apelin or placebo) was added.    -   A second steady state was reached from the 210th to the 240th        min, reflecting the “Investigational product” insulin        sensitivity of peripheral tissues of the volunteer.

Primary Endpoint

The primary endpoint (deltaGIR) was the difference between the GIRmeasured during the steady state ending the “investigational product”perfusion phase (GIRperfusion) and the GIR measured during the steadystate ending the “basal” phase (GIRbasal).

Delta GIR=GIRperfusion—GIRbasal

GIR perfusion=mean of GIR values measured at 210, 215, 220, 225, 230,235 and 240 min

GIR basal=mean of GIR values measured at 90, 95, 100, 105, 110, 115 and120 min

Secondary Endoints

-   -   Calculation of insulin sensitivity index (Si) measured at        “basal” steady state and “investigational product” steady state.

Si=M/(G×DeltaI)

Along With

M=average of the seven glucose infusion rate values measured at eachsteady-state (basal: 90-120 min and product: 210-240 min)

G=average of 7 plasma glucose values measured at each steady-state(basal: 90-120 min and product: 210-240 min)

DeltaI=difference between fasting insulin and the average of the fourplasma insulin values measured at each steady-state (assay tube serumbank collected every 10 min during the basal steady-state phases: 90-120min and product steady-state: 210-240 min)

-   -   Variations of systolic blood pressure    -   Variations of diastolic blood pressure    -   Variations of heart rate    -   Recording of ECG Changes    -   Clinical signs of intolerance/allergy/toxicity    -   Plasma insulin at all sampling time    -   Plasma glucagon at all sampling time    -   Plasma apelin at all sampling time    -   Plasma leptin at all sampling time    -   Plasma adiponectin at all sampling time

Statistical Considerations

Sample Size

To assess the primary endpoint, statistical analysis of this cross overstudy was based on a linear mixed model. In this exploratory study, fewdata was available to quantify the primary endpoint variation in humans.We hypothesized approximately a 20% increase of the glucose infusionrate at the Apelin dose causing the maximum effect on carbohydratemetabolism, namely an effect of the same order of magnitude as thatobserved in rodents.

According to data published by Muniyappa et al. showing that thecoefficient of variation of the glucose infusion rate during aneuglycemic hyperinsulinemic clamp was 0.1, and using the PASS software,for a power of 86% in a cross-over trial with an expected 20% increaseof the glucose infusion rate, 8 subjects were required for each dosetested. A total of 16 subjects were therefore included in this study.This calculation was based on the following statistical references:

-   -   Julious, Steven A. 2004. Tutorial in Biostatistics. Sample sizes        for clinical trials with Normal data.'Statistics in Medicine,        23:1921-1986.    -   Senn, Stephen. 2002. Cross-over Trials in Clinical Research.        Second Edition. John Wiley & Sons. New York.

Based on previous studies assessing the effect of different molecules,this sample size of 8 volunteers for each selected dose seemedappropriate to highlight a significant difference on the primaryendpoint.

Volunteers who early discontinue the study were replaced.

Statistical Analysis

A “per protocol” statistical analysis was performed. The description wasdone by group (Apelin or placebo), and group×period. Analysis of theeffects “group”, “period” and “interaction group×period” was based on alinear mixed model that allowed to adequately analyze the crossoverdesign and simultaneously estimate the three aforementioned effects.

-   -   If an interaction between groups and periods is highlighted,        indicating a potential carryover effect, comparisons between        groups were made on the first period only. The test of the        interaction period×group being less powerful, the significance        level was set at 0.10. In this case, only the effect “group” was        introduced in the regression model to assess the difference in        effect between the two groups. While this comparison limited to        the first period only limits the power of the statistical test,        this comparative analysis provided indications about the apelin        effect.    -   If no interaction between the group and period was highlighted        at 0.10 significance level, the two periods were retained in the        between groups comparison. In this case, the regression model        taked into account the repeated data for the same volunteer (1st        and 2nd period) by introducing a random effect related to the        voluntary and the estimate of effect “group” is adjusted on a        possible effect “period.”

The results were interpreted separately for each (pyr1)-Apelin-13 dose.

The primary endpoint was analyzed according to the strategy described inthe paragraph above.

The quantitative secondary endpoints were analyzed according to the samestrategy as the primary endpoint.

The safety and security endpoints (clinical signs of intolerance,allergy and toxicity) were described for each group (placebo/apelin) andfor each (pyr1)-Apelin-13 dose. The severity of these events wassystematically reported.

Results

The clinical characteristics of overweighed healthy volunteers includedin this trial were as follows: age 32.8+/−6.8 years, Body mass index27.60±1.42 kg/m², waist circumference 99.25±4.70 cm, body fat23.94±3.11%, fasting blood glucose 0.94±0.08 g/l, HbAlc 5.44±0.25%,total cholesterol 1.84±0.25 mg/dl, HDL cholesterol 0.46±0.06 mg/dl, LDLcholesterol 1.16±0.24 mg/dl, triglycerides 1.01±0.63 mg/dl, systolicblood pressure 119.6±8.5 mm Hg, diastolic blood pressure 73.1±7.7 mm Hg,heart rate 62.4±6.8 bpm, QTc interval 412±12 ms.

At low doses (9 nmol/kg), the apelin administration resulted in anon-significant increase in ΔGIR (difference in Glucose Infusion Rate)versus placebo (+2.21±0.54 vs +1.57±0.53+mg/kg/min, p=0.06). However, asignificant improvement in insulin sensitivity was observed with a doseof 30 nmol/kg (ΔGIR: +1.72±0.47 mg/kg/min with apelin versus+0.89±0.62mg/kg/min for placebo, p=0.03). No side effect in relation with drugadministration, and especially no severe side effect, has been observed.Specifically, apelin administration did not influence heart rate, bloodpressure, QTc interval.

CONCLUSION

These results demonstrate the insulin-sensitizing effect of(Pyr1)-Apelin-13 in healthy humans and open new perspectives for theresearch and development of therapeutic alternatives targeting insulinresistance in type 2 diabetic subjects.

REFERENCES

Throughout this application, various references describe the state ofthe art to which this invention pertains. The disclosures of thesereferences are hereby incorporated by reference into the presentdisclosure.

-   DeFronzo R A, Tobin J D, Andres R. Glucose clamp technique: a method    for quantifying insulin secretion and resistance. Am J Physiol.    1979, 237(3):E214-23.-   Muniyappa R, Lee S, Chen H, Quon M J. Current approaches for    assessing insulin sensitivity and resistance in vivo: advantages,    limitations, and appropriate usage. Am J Physiol Endocrinol Metab.    2008, 294(1):E15-26.

1. A method for preventing or treating diabetes comprising administeringto a subject in need thereof a therapeutically effective amount of anAPJ receptor agonist.
 2. The method of claim 1, wherein thetherapeutically effective amount of an APJ receptor agonist ranges from10 nmol/kg to 200 nmol/kg per day.
 3. The method of claim 2, wherein thetherapeutically effective amount of an APJ receptor agonist ranges from20 nmol/kg to 40 nmol/kg per day.
 4. The method of claim 3, wherein thetherapeutically effective amount of an APJ receptor agonist is 30nmol/kg per day.
 5. The method of claim 1, wherein the APJ receptoragonist is apelin.
 6. The method of claim 1, wherein the APJ receptoragonist is (Pyr1)apelin-13.
 7. The method of claim 1, wherein the APJreceptor agonist is an apelinomimetic.